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Based on documentation review, observation and staff interview it was determined this facility failed to meet the requirements for sprinkler coverage for the construction type according to the National Fire Protection Association, Chapter 19.1.6.2. The facility census was 18 at the time of the survey.

Findings include:

Tour of building 1 took place on 05/12/10 and 05/13/10 with staff AA and staff BB. Interview on 05/12/10 with staff AA reveals the one story main building with basement was originally constructed in 1950 and since then has underwent multiple renovations and additions beginning in 1958 and extending through 1993.
Review of the occupancy permit for the 1993 addition listed the construction as Type 2A and 2B, although after observation of the outer walls, inner load bearing walls, flooring and roof structure a determination of Type II(111) was made. The inner columns were drywall protected and the roof girders were sprayed with fire retardant material.
No documentation was available for the original building and all subsequent additions. By observation of the outer walls, inner load bearing walls, flooring and roof structure a determination of Type II(000) was made. This concrete and steel structure was observed to be unprotected in most areas including the steel beams supporting the first floor and the steel girders supporting the roof. There was a two hour fire rated constructed wall separating most of the 1993 addition from the rest of the facility. A portion of the 1993 addition surrounding the courtyard was not updated with a suppression system as the rest of the addition was. This area was located on the opposite side of the two hour fire rated constructed wall. This entire area of this building lacked the required suppression system with the exception of two small areas of which one area was the laboratory.

Additional visual verification tour was made with staff CC on 05/14/10 at 8:45 AM to 9:00 AM. Tour of the old boiler room in the basement revealed unprotected steel beams supporting the cement first floor.
On the first floor and above the ceiling tile of the west corridor side of the gift shop, observation reveals unprotected steel girders supporting the roof.

Staff CC acknowledged these finding during this tour on 05/14/10.

The above findings were reviewed with staff BB on 05/14/10 at 9:05 AM and he/she stated understanding, but held out hope for another solution than having to be sprinklered.

Based on observation and staff verification it was determined this facility failed to ensure the smoke barriers were constructed to provide at least a half hour fire resistance rating in accordance with the National Fire Protection Association (NFPA) 101, Chapter 19. This had the potential to affect all those utilizing this facility. The total patient census during the survey was 18.


Findings include:

Tour of the smoke and fire barriers for building 1 took place on 05/12/10 with staff AA and staff BB. Penetrations were observed in the following locations above the ceiling tile:

* Above the door leading into the maternity department a small round penetration was observed around wires.
* Several feet north of the gift shop area an approximate two inch by 10 foot gap was observed between the concrete block and bottom of the roof. Additionally, observation was made of an approximate eight inch by eight inch opening in the block with wires passing through.
* Outside of the equipment room an approximate four inch by 12 foot gap was observed between the concrete block and bottom of the roof.

These findings were observed and verified by staff AA during the tour on 05/12/10.

Based on observation and staff verification it was determined this facility failed to ensure that all doors located in smoke barriers are equipped with a self-closing device. This had the potential to affect all those utilizing this area of the facility. The total patient census during the survey was 18.

Findings include:

Tour of the smoke and fire barriers took place on 05/12/10 with staff AA and staff BB. Observation was made of a door located in the smoke barrier just outside the maternity department which lacked the required closing mechanism.

This finding was observed and acknowledged by staff AA and staff BB during the tour on 05/12/10.

Based on observation during tour and staff verification it was determined this facility failed to ensure that all exit accesses were arranged to provide a safe transition from the building to a paved public way for all peoples utilizing this facility. The total patient census at the time of the survey was 18.

Findings include:

During tour of the exit discharges on 05/13/10 with staff AA and staff BB, observation was made of three exit discharges which did not provide safe travel to a paved public way from the building. These areas are:
1) On the south side of the MRI department outside of the exit access observation was made of an approximate nine by six foot cement stoop surrounded by grass. There was approximately 108 feet of grass between the cement stoop to the nearest paved public way.
2) On the north side of the MRI department outside of the exit access, observation was made of an approximate four by twenty foot cement ramp that ended in the grass. There was approximately 170 feet of grass between the end of the cement ramp to the nearest paved public way.
3) Just outside the west exit access from the maternity department observation was made of of an approximate six by twenty-one foot cement ramp that ended in the grass. There was approximately 96 feet of grass between the end of the cement ramp to the nearest paved public way.

These findings were observed and verified by staff AA and staff BB during the tour on 05/13/10.

Based on record review and staff interview it was determined this facility failed to maintain documentation in order to verify the emergency lights have been tested on a monthly and annual basis. The total census of this facility on the day of the survey was four.

Findings include:

During record review of emergency light preventive maintenance on 05/12/10 observation was made that the annual 90 minute emergency light tests and all of the monthly tests for 2009 were not included with the documentation provided. The question was proposed to staff AA if these could be provided. Staff AA stated he/she would look for them but did not think they were available.
On 05/14/10 during interview with staff BB at approximately 10:00 AM verification was made that this facility did not have the necessary annual or monthly documentation for the 2009 preventative maintenance for emergency lights.

Based on staff interview it was determined this facility failed to perform the required annual smoke detection testing and sensitivity testing according to the National Fire Protection Agency (NFPA) 101, 2000 edition Chapter 9.6.1.3 and NFPA 72 3.2.1. This had the potential to affect all those utilizing this sleep lab. The total patient census at the time of the survey was zero.

Findings include:

Documentation review for the testing and maintenance of smoke detectors took place on 05/12/10. The documentation for the testing and maintenance of the smoke detectors for the sleep lab was not included. A request was made for this documentation on 05/13/10 at 2:50 PM and staff AA stated they have not been doing the required testing of these smoke detectors and therefore do not have any documentation. This interview verified this finding.

Based on documentation review, observation and staff interview it was determined this facility failed to ensure the cooking hood systems were equipped with the required UL-300 fire suppression system. This had the potential to affect all those utilizing this facility. The current patient census during the survey was 18.

Findings include:

Tour of the kitchen facility was conducted with staff AA and BB on 05/13/10. Observation was made of the current suppression system which did not identify itself as UL-300 compliant. Review was made of the documentation for the semi-annual hood system test performed by a professional outside company on 06/02/09 and 10/09/09. These documents reveal the last time the six year maintenance was performed on this system was on 12/08/08. The hydrostatic testing was not due for several years later.

This finding was acknowledged by staff AA during interview on 05/13/10 at approximately 3:45 PM when he/she stated "this system should have been upgraded during the last six year maintenance."

Based on observation and staff verification it was determined this facility failed to protect the medical gas storage area in accordance with the National Fire Protection Agency (NFPA) 99, in regards to electrical switches located in medical gas storage areas. This had the potential to affect all those utilizing this area.

Findings include:

During tour of the medical gas storage area on 05/13/10 with staff AA observation was made inside the medical gas storage room of a light switch which was located on the wall just inside to the left of the door. A measurement was taken of the distance between the bottom of the switch plate and the floor. It was measured at four feet, one foot short of the required five foot distance.

This finding was acknowledged by staff AA during tour of this room on 05/13/10.

Based on observation during tour and staff verification this facility failed to ensure smoke detectors were located where air flow patterns would not disrupt their normal operation as required by NFPA 72 Chapter 2-3.5.1. This had the potential to affect all those utilizing this facility. The facility census was 18 at the time of the survey.

Findings include:

During tour of the main building on 05/13/10 observation was made of several smoke detectors located in areas where air flow may inhibit their normal operation. These were located in the following areas:

Basement
* Two in the kitchen prep area
* One in the east wing basement classroom

First floor
* One near the southeast door of the radiology department
* One near the physician's lounge
* One in the pharmacy department
* One in the women's health department

These findings were acknowledged by staff AA and Staff BB on 05/13/10 when they both stated they will all be relocated properly.